Do I Need to Be Healthy to Qualify for Medicare Coverage? – Frequently Asked Questions

If you have health issues and you’re new to the Medicare program, you could wonder whether this may affect your Medicare coverage. Learn how Medicare works when it comes to health status.

Medicare coverage of pre-existing conditions

In general, Original Medicare (Part A and Part B) covers any pre-existing conditions you had before you became eligible for Medicare. Some people can even qualify for Medicare coverage because of certain health conditions: disabled individuals and those with end-stage renal disease (ESRD) or Lou Gehrig’s disease may become eligible for Medicare coverage before 65.

So, your health status at the time you enroll shouldn’t affect your Medicare coverage. It’s a good idea to enroll when you’re first eligible for Medicare coverage to avoid late-enrollment penalties, but your Original Medicare coverage and costs shouldn’t otherwise be affected due to your health.

Medicare Advantage and Medicare coverage of end-stage renal disease

Things work differently if you have end-stage renal disease and want Medicare coverage through Medicare Advantage (Part C). While Medicare Part C must cover at least the same level of benefits as Original Medicare, you’re generally not allowed to get Medicare coverage through a Medicare Advantage plan if you have ESRD at the time you apply for enrollment.

There are some exceptions. You may also be able to get Medicare coverage through a Special Needs Plan, a special type of Medicare Advantage plan that limits enrollment to those who live in an institution; have both Medicare and Medicaid coverage; or have certain chronic health conditions, such as cancer or ESRD. If there’s a Chronic-Condition SNP targeting people with ESRD in your service area, you may be able to get Medicare coverage this way.

Medicare Supplement and Medicare coverage of pre-existing conditions

Another time when your health status could affect your Medicare coverage is if you’re purchasing Medicare Supplement (Medigap) insurance. These plans are meant to work alongside your Original Medicare coverage to fill “gaps,” such as copayments, coinsurance, and deductibles.

The best time to enroll is during your Medicare Supplement Open Enrollment Period, the six-month window when you’re 65 or older and have Part B. During this period, you have “guaranteed-issue rights” and can’t be turned down for coverage or charged more because of health issues. Once this period is over, insurance companies can require medical underwriting, charge you higher premiums, or reject you outright because of health status. Please note that you may have to face a waiting period of up to six months before the Medicare Supplement plan covers your pre-existing conditions, even if you enroll during your Medigap Open Enrollment Period.

Would you like help exploring Medicare coverage options that may fit your needs? I’d be happy to go over any questions you have. To get started, use the links below to schedule a phone appointment or request plan information via email. Prefer to look on your own time? Click the Compare Plans button to view plan options now.

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